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South Asia Investor Review is focused on reporting, analyzing and discussing the economy and the financial markets of countries in South Asia, including Pakistan, Bangladesh and Sri Lanka. For investors looking to invest in emerging markets beyond BRIC countries (Brazil, Russia, India and China), this blog is designed to help international investors looking to learn about investing in South Asia with focus on Pakistan. Riaz has another blog called Haq's Musings at http://www.riazhaq.com

India Medical Tourism: Pakistanis Spend the Most Per Patient

As Indian medical visas granted to Pakistani patients regularly make headlines in India, it is hard not to conclude that it's all part of a PR campaign by the Hindu Nationalist Modi government in India.

What is often left out of the media stories is the minor detail that Pakistanis pay more to use services of for-profit Indian hospitals than do people of other nationalities for such "humanitarian gestures".

Pakistan is an important and lucrative source of medical tourism dollars in India. The kind of facilities Pakistanis pay to use in India are not accessible to poor Indian masses who must rely on India's decrepit public health system.

A 2017 report by Indian ministry of commerce and industry says an average Pakistani spends Rs 187,000 on treatment in India. Those from Bangladesh spend Rs 134,000 on an average, followed by those from Commonwealth countries (Rs 125,000), Russia (Rs 104,000) and Iraq (Rs 98,554).

Times of India quoted Manish Chandra of Vaidam medical travel agency as saying: "This is because Pakistani patients mostly come for organ transplants and heart surgeries for children that are costly." In 2015-16, he said, nearly 166 Pakistanis received treatment in India every month. Top Delhi hospitals, which are frequented by foreign nationals, confirmed this.

Most of the Pakistani patients suffering from liver and heart ailments go to major for-profit hospitals in Delhi, Mumbai, Chennai and other cities, according to TOI. The number of Pakistani patients, however, has seen a sharp drop since February this year when the Indian government decided to stop granting medical visas to retaliate after Pakistan handed out a death sentence to Indian spy Kulbhushan Jadhav. In other words, humanitarian concerns take a back seat to Modi government's policies to assert India's dominance in the region.

The Times of India sums up the situation as follows: India's imposition of restrictions on the issue of medical visas to Pakistanis has not just affected hundreds of patients from across the border but also dealt a body blow to medical tourism in India.

The highest average earnings per patient through export of health services from India comes from Pakistan at $2,906. Pakistan is followed by Bangladesh ($2,084), CIS (Commonwealth of Independent States) countries ($1,950), Russia ($1,618) and Iraq ($1,530), according to a first of its kind survey on export of health services by Directorate General of Commercial Intelligence and Statistics, under the commerce ministry. This means a patient from Pakistan visiting a hospital in India spends more than people from any other country, boosting India’s foreign exchange reserves.

However, the number of medical visas issued to Pakistani patients in 2015-16 stood at a measly 1,921 compared to 58,360 to patients from Bangladesh and 29,492 to patients from Afghanistan. Due to the low number of medical visas issued, Pakistan contributed only $6 million to India’s services exports compared to $343 million by Bangladesh in 2015-16.

India has emerged as a top-notch destination for medical value travel because of its world-class healthcare facilities and affordable price. India aims to significantly promote medical tourism and has recently liberalized its e-visa system for most of the countries except Pakistan.

In the health tourism portal maintained by the services export promotion council as a one-stop for overseas patients, there is no specific information on how patients from Pakistan can obtain a medical visa. The same information is available for patients from 16 countries, including Bangladesh and Afghanistan.

The tension between the two South Asian neighbours has risen after a Pakistan military court handed a death sentence to captured Indian national Kulbhushan Yadav who Pakistan alleges is an Indian spy. India has denied the charge and has repeatedly asked for consular access to Yadav that Pakistan has refused time and again. There are reports that India may further restrict visas to Pakistani nationals, though another report claims visas will be issued to Pakistan nationals only on medical ground.

Pakistani nationals can get visitor visa of six months to meet relatives or friends or any other legitimate purpose and the duration of stay in India at a time shall not exceed three months. “However, senior citizens (above 65 years of age) or a Pakistan national married to an Indian and their children below 12 years of age accompanying parents may be granted two years visit visa with multiple entries subject to certain conditions,” minister of state in the ministry of home affairs Kiren Rijiju said in response to a question in Rajya Sabha earlier this month.

Why do so many Indians travel abroad for medical treatment? Why did Sonia Gandhi go overseas for treatment in March 2017?

Why do Indians import almost all of their surgical instruments from Pakistan? Why do Indians depend heavily on Chinese imports for almost everything? Why don't they do it all themselves?

Or for that matter, why do nations trade? Why does't each nation make everything and provide all services within the country? Surely, a nation as large as India with over a billion strong consumer market should be able to do that?

Why does US depend so heavily on Chinese imports? Even for critical parts of their advanced fighter jets and other defense equipment? Surely, a nation as advanced as US should do it all themselves.

The umbrella term “surgical instruments” summarises the specific and mostly hand-held instruments used during an operation or a surgery (e.g. scalpels, clamps and forceps). Worldwide these instruments are mainly produced in two traditional clusters – in Sialkot, Pakistan and in Tuttlingen, Germany. Together, these clusters supply up to 75 % of the world demand of traditional hand-held stainless steel surgical instruments [1]. As Figure 1 illustrates, not all of the instruments made in Pakistan are directly sold to the end customer. Instead, many of the Pakistani instruments are first transported to Germany where they often get final finishing and quality control [2].

The Penn Effect is that prices of goods and services in developed countries (DCs) are, after using market exchange rates, substantially higher than those in less-developed countries (LDCs). The World Bank in 2015 estimated that prices are more than three times higher in the US than in India. This price differential is huge. This raises some interesting questions.

Why aren’t very many tourists from the US attracted to India, if the prices are very low in India? Also, the price differential can be attractive to migrants who had initially shifted from India. In their retirement years, the migrants could return home but this hardly happens.

Prices in the US are, as mentioned earlier, more than three times the prices in India. Let us consider this number in perspective. Pension funds in the US are, as discussed by Richard A. Marin, still going through a near-crisis as they have large unfunded liabilities. The size is still debated. If the shortfall is a quarter of the liabilities, then on one hand, a shortfall of 25% is viewed as a near-crisis. On the other hand, there is an opportunity to get 200% more by shifting to India! But we do not see this behaviour.

there is often a risk in purchases. For example, medical charges can be relatively low in India but there is a question mark about the competence of a medical practitioner (and even about the arrangements in many hospitals). So, the risk-adjusted price can be higher than the observed price.

quality is low in India. This is well known but not adequately appreciated. For example, while the cost of higher education in India is low, the quality too is typically quite low. So, the quality-adjusted price of education can be high in India.

It is true that the use of market exchange rates can underestimate the gross domestic product of a country like India relative to that of a DC. So many economists advocate the use of exchange rate based on PPP. However, this can overestimate the GDP in India. So, it may help to consider adjusted-PPP to get the correct picture.

In August, at least 386 children were reported to have died at a public hospital in the north Indian city of Gorakhpur in Uttar Pradesh. This sudden rise in fatalities at the Baba Raghav Das (BRD) Hospital placed India's healthcare system under scrutiny. Authorities attributed the increase to a seasonal encephalitis outbreak, but others have placed the blame on corruption within India's public healthcare system.

According to the United Nations, in India, about 48 out of every 1,000 newborns die before reaching the age of five. It is one of the highest under-five child mortality rates in South Asia (behind Afghanistan at 91 and Pakistan at 81). In terms of numbers, India has the largest share of global under-five deaths at 1.3 million annually.

About five percent of the Indian government's annual expenditure goes towards healthcare. According to the World Health Organization (WHO), most of the healthcare expenditure in India - which averages $75 per capita - comes from the private spending of households.

The standards of India's public healthcare system contrast starkly with its private counterpart, which generates billions of dollars annually from medical tourism.

For local Indians, the cost of private healthcare is about four times greater than the country's public healthcare. About 72 percent of residents of rural areas and 79 percent of residents of urban areas use private healthcare services.

Currently, India gets 70-80% of its medicines and medical devices supplies, including raw material for pharmaceuticals (Active Pharmaceutical Ingredient) from China. This poses a major risk of severe drug shortage if India's diplomatic relations with China worsen.

In fact, in 2014, National Security Adviser Ajit Doval had also warned the government about India's over-dependence on China for API and how the tension between the two countries can cause a crisis in the public health ..

Youths would later tell the police that the couple, both 24, had offended them by ignoring their greetings and kissing in front of them. Not so, Ms. Droz told The Times of India. They were trying to force her to take selfies with them, Mr. Clerc added. Eventually, they began beating the couple with sticks and rocks.

By the time a crowd had gathered and the youths had run away, he had a fractured skull and possibly permanent hearing damage and she had a fractured left arm. “The blood was flowing,” said Ram Kishor, a police constable in the area.

The assault late last month made headlines for several days in India. It was a fresh setback for tourism in this part of the country, which is home to some of the world’s most famous monuments but finds its status threatened by disputes about its Muslim heritage, amid reports of declining visitor numbers and of harassment of tourists.

Stops at Fatehpur Sikri and in the nearby city of Agra to see the Taj Mahal, all of which are in Uttar Pradesh State, are at the top of many itineraries for tourists in India. Built in the 17th century by the Muslim emperor Shah Jahan as a tomb for his wife, Mumtaz Mahal, the Taj Mahal attracts millions of visitors every year. Tour operators call it India’s monument to eternal love.

But Hindu nationalists, some of them aligned with the governing Bharatiya Janata Party, have taken aim at the Taj Mahal and its ties to a Muslim ruler.

During a trip to Agra in June, Yogi Adityanath, the chief minister of Uttar Pradesh, said at a rally that small replicas of the monument given to foreign dignitaries “did not reflect Indian culture.” Other far-right leaders went further, describing it as having been built by “traitors” who “wanted to wipe out Hindus.”

But Mr. Adityanath seems to be softening his stance, at least in public. When he visited Agra in late October, he called the Taj Mahal a “unique gem.” A tourism brochure published by the state government that initially omitted the Taj Mahal has been updated to include it.

Tour guides said the controversy had hurt their business.

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On a recent day, a throng of tourists formed a line at the mouth of the Taj Mahal complex, pressing their bodies forward. Among them was Vital Labonte, 66, a French Canadian visitor in hiking boots, who said the occasional jostle or appeal for money did not bother him.

“The kids run at you, they want money to better their life,” he said. “Just say no. I’m not worried with it.”

Viktoria Simeoni, 23, an Austrian visitor who had booked a trip to India on a whim, said she sometimes felt unsafe when men stared at her or asked for pictures, a request often made to foreign tourists in India.

“One lady gave me her baby,” she said. “I was just holding the baby, and then she took pictures of me. I didn’t feel so comfortable.”

The police found it necessary to crack down. In the days after the attack, they arrested over 50 people they accused of being touts with reputations for hounding tourists.

In Fatehpur Sikri, officials emphasized that the severity of the attack against the Swiss couple was rare. The crime that tourists report most often is theft.

A newborn baby, declared dead by a hospital in the Indian capital Delhi, was found to be alive while they were on their way to his funeral.Doctors at the privately run Max Hospital had pronounced the baby dead hours after his twin who was stillborn.The parents said they noticed one of the babies squirming inside the plastic bag that doctors placed the infants in.The incident has sparked outrage and a debate over the quality of private healthcare which is often costly.

Delhi Chief Minister Arvind Kejriwal tweeted that he had ordered an inquiry into the matter. The state health minister has also described the incident as "shocking criminal negligence".

According to the twins' grandfather, the stunned family rushed the newborn to a nearby hospital where they were told that their baby was still alive, local media reported.

In a statement to reporters, Max hospital said they were "shaken" and "concerned" over the incident, and added that the doctor has been asked to go on leave, pending an inquiry.

According to ANI news agency, Delhi police have begun to investigate the case and have consulted legal experts.This is the second instance in recent months where a private hospital in India has been called out for negligent care. Last month, a girl died of dengue fever in another hospital and the parents allege they were overcharged for her treatment.

It may have looked moth-eaten to its founder Mohammad Ali Jinnah, but Pakistan was anything but that at the time of Independence. An average Pakistani was richer, lived longer and lived more safely than an average Indian for almost two decades after 1947, which is roughly the time democracy was absent in Pakistan.

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What can India offer to Prime Minister Khan that’s new, substantive and outside the immediate no-go areas of J&K and terror? We should first banish the thought that a weak Pakistan is good for us. A crippled Pakistan is only good for two things: 1. Shouting matches on TV where those criticising India are asked to migrate to Pakistan. 2. To give us a false sense of achievement in doing better than Pakistan when India’s potential-performance gap is much wider than Pakistan’s.

A less hostile public attitude toward our neighbour will allow government to take a few out-of-the box steps. For instance, Indian companies should be allowed and encouraged to hire from top Pakistan campuses, even if for one or two years. If only 30 Sensex companies hire 50 Pakistanis each, there will be 1,500 young and talented Pakistanis working and living in India benefiting, and benefiting from, the world’s 6th – and soon to be 5th – largest economy. Companies will get good talent at competitive salaries – Pakistani rupee is nearly half the value of Indian rupee. For those worrying about a job loss for Indians, 1,500 is only 0.0007% of Sensex companies’ workforce.

Imran Khan’s passport has more Indian visas than any prime minister of Pakistan. Unfortunately, India allows only the rich and powerful in Pakistan to benefit from India’s soft power. That’s counterproductive to our own interests. We should want average Pakistanis to see India as a source of good to them. They will then begin to resent whatever power comes between that ‘good’ and them – whether that power is in Rawalpindi or Islamabad or Beijing – or even Srinagar.

Aspiring cricketers in Pakistan will dream of playing in IPL if we unblocked their entry. A budding artist (actors, singers, comedians …) in that country will look forward to hitting the big stage in India, if we don’t hum and haw over granting him a visa. Pakistanis with a critical medical condition in the family should want to get treatment in India – without having to try their luck on Sushma Swaraj’s Twitter handle. Pakistan should be allowed to fill its quota of students at the South Asian University, something we committed to at the time of deciding to host this institution that could one day be the region’s most coveted.

Not one of these will be acts of charity or concession because India’s gains will be as much as Pakistan’s – if not more. This is exactly what we tell the US while arguing for easier immigration. In geopolitics there is no positive emotion as powerful as seeing your countrymen excel in another country. India has that power in its grasp today. Let’s use Imran’s prime ministership as an occasion to unleash that power.

#UAE to build first ever #medical mall in #Islamabad, #Pakistan. The project will include therapeutic and recreational areas, a regional #Cardiology center, an orthopedic centre and 400-bed #university #hospital. https://www.thenews.com.pk/latest/357797-uae-to-build-first-ever-medical-mall-in-pakistan

A prominent UAE-based MBF Group has announced to establish an integrated medical city that will also feature a first-ever medical mall of the country in Islamabad.

The agreement of MBF with Ibchez Housing and Nixon, according to the report, will include the construction of a hospital that will provide medical services at international standards.

The founder and owner of MBF Group Shaikh Mohammad Bin Faisal Al Qasimi ,in an interview with the Gulf news said the project will include a 400-bed university hospital that will offer the most advanced levels of healthcare services.

The medical city will also feature the country’s first medical mall, therapeutic and recreational areas, a regional cardiology centre, and an orthopedic centre, he added.

He noted that the city will include a nursing college and is expected to serve some one million patients and clients on a monthly basis.

There is a need for such advanced hospitals to serve Pakistan’s growing population, he stressed.

Shaikh Mohammad pointed out that the investment provided for the medical city has reached US$970 million (Dh3.52 billion), while noting that its land has been purchased, as well as the desire of all parties to complete the project on time, in a bid to answer the growing demand for medical services in Islamabad and provide specialist health services that are in short supply.

He informed that the group will manage the city’s 1,000 medical, technical and administrative staff, who will all be Pakistanis, and is responsible for providing medical equipment and beds.

Not all is well with #India's corporate #hospital chains. The sharpest dip is witnessed in the National Capital Region (NCR), where operating margins have declined by 21 percentage points. #medical #health #tourism https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/not-all-is-well-with-indias-corporate-hospital-chains/articleshow/65545784.cms

Four of India’s large publicly traded hospital chains — ApolloNSE 4.37 %, Narayan Health, Fortis and Max IndiaNSE -1.34 % — have cumulatively lost `6,300 crore in market cap in the last two years, an analysis by ET Intelligence Group showed. A report by rating agency ICRA in July revealed that profitability of hospitals have touched a multi-year low.

“The health of the hospital sector has been deteriorating since early CY2017 due to several factors that have adversely affected its profi ..

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I am the Founder and President of PakAlumni Worldwide, a global social network for Pakistanis, South Asians and their friends. I also served as Chairman of the NEDians Convention 2007. In addition to being a South Asia watcher, an investor, business consultant and avid follower of the world financial markets, I have more than 25 years experience in the hi-tech industry. I have been on the faculties of Rutgers University and NED Engineering University and cofounded two high-tech startups, Cautella, Inc. and DynArray Corp and managed multi-million dollar P&Ls. I am a pioneer of the PC and mobile businesses and I have held senior management positions in hardware and software development of Intel’s microprocessor product line from 8086 to Pentium processors. My experience includes senior roles in marketing, engineering and business management. I was recognized as “Person of the Year” by PC Magazine for my contribution to 80386 program. I have an MS degree in Electrical engineering from the New Jersey Institute of Technology.
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